Most Definitive Study to Date on Effectiveness of HIV Counseling and Testing Finds Significant Reduction in Sexually Transmitted Diseases:

Counters Previous Beliefs on Approach to Prevention

A simple change in HIV and STD counseling across the nation could make
a tremendous difference in slowing the spread of HIV and other STDs, suggests
new data from the Centers for Disease Control and Prevention (CDC). Researchers
found that when counselors "encourage" and "discuss" prevention
strategies with people at risk, rather than simply providing a "lecture" on
HIV prevention, it significantly reduces their risk of STDs.

In a study involving nearly 6,000 heterosexual men and women attending
STD clinics in five U.S. cities, CDC found that talking with, rather
than to men and women at risk actually resulted in a 20% decrease in new STDs
among study participants overall, and a 40% decrease among adolescents and
people diagnosed with an STD on their first visit.

Additionally, the study, published in the October issue of the Journal
of the American Medical Association, found that the "encouragement" approach
was just as effective in two brief twenty-minute counseling encounters as
in a more extensive, four-session program. These findings indicate that,
if well designed, brief interventions can make a significant impact.

"This study showed that it's not how much you talk to people about
HIV prevention that matters most - but how you talk to them, especially
if people are encouraged to participate in developing their own prevention
plan," said Helene Gayle, Director of CDC's Center for HIV, STD, and
TB Prevention, NCHSTP.

According to CDC, the brief sessions used in this study were not only as
effective as the longer four-session intervention, but are feasible to implement
in busy health care settings.

Counseling was provided to HIV-negative heterosexuals at five public STD
clinics in Baltimore, Denver, Long Beach, Newark, and San Francisco who
came in for STD examinations. Participants were followed for twelve months
to measure new STDs (gonorrhea, chlamydia, syphilis, and HIV) and self-reported
condom use. The study is one of the few studies to date to measure not only
condom use, but also disease outcomes.

Findings at each of the five sites showed a significantly lower incidence
of STDs among both men and women participating in interactive counseling
sessions, with the greatest impact among adolescents and individuals diagnosed
with an STD at their initial visit.

"The program seems to make the greatest difference for those who need
it most," said Dr. Kevin De Cock, Director of NCHSTP's Division of
HIV Prevention - Surveillance and Epidemiology. "We know that the majority
of new STD infections, including HIV occur among teens and young adults,
and the interactive approach reduced risk among young people and others
at high behavioral risk."

CDC believes that while the program was tested in STD clinics, the findings
are likely to have relevance in any setting in which HIV and STD counseling
is provided. Rather than simply providing the facts regarding how HIV transmission
can be prevented, counselors in this program engage in a conversation with
the individual at risk to identify a small behavior change the patient is
willing to make. Counselors then build on this "first step" in
the second session to develop a long range risk-reduction plan.

Lead CDC investigator on the study, Mary Kamb, M.D., M.P.H., explained
how the conversation needs to differ from the current approach. "Instead
of beginning with 'these are the facts about transmission and how to protect
yourself', the counselors asks questions like - 'what's the one thing you
think you could do next week to reduce your risk? How would you try bringing
up using condoms with your partner?'"

In this study, the approach was implemented with existing clinic staff,
in not much more time than that required for didactic messages, and cost
only $8 additional dollars per client to implement. The costs were primarily
related to training counselors and assuring the quality of counseling on
an ongoing basis.

"Far too often, prevention programs found to be ideal in research
settings are too difficult and expensive to implement in the real world," said
Kamb, "With this program the ideal can be real, with few additional
resources.'

As a result of these findings, CDC hopes that the approach will be widely
adopted in STD clinics and other health care settings across the nation.
CDC is refining its 1993 HIV Counseling and Testing recommendations to provide
even more specific guidance on incorporating this now-proven approach to
risk-reduction counseling. CDC will also provide technical assistance to
facilities including training existing staff and monitoring the quality
of counseling provided at clinics. According to CDC, clinics may have been
reluctant to adopt this approach in the past because they didn't believe
it worked better than didactic counseling or because they felt it was too
costly and difficult to implement. This study should help put both fears
to rest.

"When you compare an $8 investment in HIV prevention to the estimated
$154,000 in lifetime treatment costs and the tremendous human suffering
caused by HIV infection, there is no question that this investment is worth
making," said Gayle.